(a) The rules in this section apply when a prior authorization
(PA) request is submitted with incomplete or insufficient information
or documentation on behalf of a member who is not hospitalized at
the time of the request.
(b) In this section, "incomplete PA request" means
a request for service that is missing information or documentation
necessary to establish medical necessity as listed in the PA requirements
on the managed care organization's (MCO's) website.
(c) An MCO must comply with Title 42 Code of Federal
Regulations §438.210, applicable provisions of Texas Government
Code Chapter 533, and the PA process and timeline requirements included
in an MCO's contract with the Texas Health and Human Services Commission
(HHSC).
(d) If an MCO or an entity reviewing a request on behalf
of an MCO receives a PA request with incomplete or insufficient information
or documentation, the MCO or reviewing entity must comply with the
following HHSC requirements.
(1) An MCO reviewing the request must notify the requesting
provider and the member, in writing, of the missing information no
later than three business days after the MCO receives an incomplete
PA request.
(2) If an MCO does not receive the information requested
within three business days after the MCO notifies the requesting provider
and the PA request will result in an adverse benefit determination,
the MCO must refer the PA request to the MCO medical director for
review.
(3) The MCO must offer to the requesting physician
an opportunity for a peer-to-peer consultation with a physician no
less than one business day before the MCO issues an adverse benefit
determination.
(4) The MCO must make a final determination as expeditiously
as the member's condition requires but no later than three business
days after the date the missing information is provided to an MCO.
(e) The HHSC requirements for MCO reconsideration of
an incomplete PA request do not affect any related timeline for:
(1) an MCO's internal appeal process;
(2) a Medicaid state fair hearing;
(3) a review conducted by an external medical reviewer;
or
(4) any rights of a member to appeal a determination
on a PA request.
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